Is there a plan B to integrated care?

Delegates to the recent NHS Confederation conference in Liverpool could be forgiven for thinking that the latest NHS target was to achieve vertical integration as soon as possible. I am talking here not about community services providers being snapped up by Trusts, but about integration between primary, secondary, community and in some cases social care.  ‘If this isn’t it, what is plan B?’ opined a speaker from NHS Manchester.

It’s true – integration seems to be spreading across England, given huge impetus by the financial challenge. In the absence of much formal evidence of impact, NHS staff are using common sense to spot where care may be fragmented and inefficient, and where there may be gains from working with local councils to improve health in specific communities. 
 
All eyes are on stemming the relentless rise in emergency admissions. Our analysis shows that demand for emergency care across England is greater than would be expected looking at aging and illness levels; is driven by a rise in short-stay admissions; and is only marginally affected by recent policies such as payment by results, the four hour A&E target and foundation trust status. 
 
Long run developments in medicine and management are resulting in shorter lengths of inpatient stay, which in turn is helping to suck in more admissions. Admitting doctors are often junior, have little knowledge of, communication with or confidence in out-of-hospital care, and have high discretion over whether to admit patients. GPs have few obvious incentives to reduce avoidable emergency admissions. 
 
If there is a bed, as I remember from SHO days, it is simply easier to admit a patient. More integrated communication between clinicians, IT, aligned incentives, and training would, it is argued, help provide the reverse thrust on emergency admissions needed. But if all roads lead to integration you say, won’t this lead to inert monopoly? As our recent publication, Where next for integrated care organisations in the English NHS? , pointed out: where is the external challenge from, say competition, that will keep the NHS on its toes? And what about patient choice?
 
The biggest external challenge on the NHS is by far the impending financial stringency – next to this, the impact of competition, as it now is, is weak. And creating more now may be an unhelpful distraction given limited management time. 
 
But in a financially rosier future, would NHS North West for example be innovating in the way it is now without the sword of Damocles hanging over it? Probably not – and this is why competition should still be built into the system as an antidote to inertia.  
 
But perhaps to follow Saint Augustin, ‘give us competition, but not yet’ might be a more appropriate approach to policy under the circumstances.  
 
On the other hand, competition internal to the integrated network/organisation might be easier to design. For example, between providers who do not require much capital to set up: primary and ambulatory care providers, GP commissioning groups, and social care providers. It is here where policy designers should concentrate in the next few years.
 
But who exactly will be these policy designers? The policy statements from the new Coalition Government and the DH signal a decentralised approach to reform. GP commissioners have a long road ahead of them to develop as organisations– as we along with five other organisations detail in our recently published report: Giving GPs budgets for commissioning: what needs to be done? 
 
SHAs and PCTs will be busy slashing administrative costs by an eye- popping 45 per cent. The new NHS Commissioning Board (now NHS England) will be busy forming and not operating until April 2012. The new economic regulator is under construction, and the Cooperation and Competition Panel is not meant to design system reforms.
 
This degree of turbulence gives opportunity for edgy local initiative – for example to pursue integration where it makes sense. But unless we collectively recognise that in the pursuit of health, medical care is a small aspect, we are sleepwalking into far bigger problems in the long run.